Skip to main content

A 65 year old female e log

 

65 year old female patient with seizure

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 65yr old female resident of lingotum with history of seizures 

Chief complaints:-


The patient was brought with chief complaints of Active involuntary movements 5 days back, history of frothing , mouth deviation to left  uprolling eyeball ,no h/o of tongue bite, urinary incontinence, fever, head injury, vomitings, loose stools.

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 11 days back later she developed her first episode of seizure with sudden onset of movements in upper and lower limbs for 5 minutes.
The episode began with headache and dizziness, up-rolling of the eyes followed by loss of consciousness and uncontrolled involuntary movements of the arms and legs, clasping of the hands and deviation of the mouth to one side. She regained consciousness 5-10 minutes later in a confused state, with no memory of the episode. She was brought to the hospital by her son where she was prescribed levetiracetam and she left the day after.


Second episode began in the night time 5 days back (on 2/12/23) and  had complaints of headache dragging type pain radiating to neck . This was followed by up-rolling of the eyeballs loss of consciousness and sudden onset of involuntary movements,  frothing,  deviation of mouth towards left and confusion in postictal period.

No h/o episode of seizure activity after bringing to casualty 

no h/o of involuntary defecation

no h/o fever, cough, vomitings, loose stools, pain in abdomen.

PAST HISTORY:-
Similar episode 5 days ago for which she visited a local hospital and got treated .
K/C/O hypertension since 18 years on medication not a known case of DM/HTN/TB/Asthma/CVD/CAD

TREATMENT HISTORY:-

On treatment for hypertension since 18 years 

Personal History -

Appetite - Normal 
Diet - mixed 
Bowel and bladder movement are regular
Sleep adequate 
No addictions 

Family history - not relevant

General examination
Patient is conscious, coherent and cooperative 
Moderately built and nourished 
Pallor absent 

Icterus - Absent



Cyanosis - Absent

Clubbing - Absent



Lymphadenopathy - Absent

Pedal edema-absent

VITALS:-

Tempurature - 98 F

Pulse- 78 bpm 

Blood pressure - 140/90 mmhg

Respiratory rate - 18 cpm

spo2- 99

grbs- 117 mg %

SYSTEMIC EXAMINATION:-
CNS examination

Motor system
Bulk - no wasting of muscle 
Tone - normal 
Power grading - 
                       Right.          Left 
Upperlimb       +5.              +5
Lowerlimb       +5.              +5

Reflexes - 
Biceps - normal 
Triceps - normal
Knee jerk present
Ankle jerk present

Sensory system - fine touch , crude touch , pain , temperature sensation are intact 

CVS examination

Inspection:-

JVP not seen

Auscultation

S1 S2 heard , no murmurs 

RESPIRATORY SYSTEM

chest is bilaterally symmetrical 

bilateral airway entry present

trachea - central

no scars

Percussion:-Resonant in nine quadrants

Auscultation- Normal vesicular breath sounds heard

ABDOMINAL EXAMINATION

No local rise of temperature 

no tenderness

No organomegaly

Investigation - 
Glycated hemoglobin 

Lipid profile 

Fasting blood sugar 

RFT

Hemogram 

Ultrasound report


MRI



Provisional diagnosis -
This is a case of 65 year old woman who came with complaint of abnormal movement of hands and limbs lasting for 5 mins preceded by headache suggestive of generalized tonic clinic seizure.
 
Treatment
Inj. Levipil 500 mg IV 
Tab Clinidipine 18 mg OD 
Tab Shelcal 500mg OD
Tab  Neirobion Forte OD 

Comments

Popular posts from this blog

OSCE learning points

Learning points  - This is a case of 65 year old female with Generalised Tonic Clinic seizures  Osce questions 1) Reasons for seizures in old age people  * Neurodegenerative disorders * Cerebrovascular disorders  * Dementia  * Metabolic disorders      - Hypoglycemia      - electrolyte imbalances     - uraemia * Physical or mental exhaustion  2) pathophysiology of seizures  * To function normally brain must maintain a continual balance between excitation and inhibition , remaining responsive to environment while avoiding continued unrestrained  spontaneous activity * GABA inhibitory neurotransmitter acts on ion channels , enhances inflow of chloride and reduces formation of action potential  * Excitatory amino acids allow  influx of sodium and calcium and producing opposite effects  * It is likely that many seizures results from an imbalance between this excitation and inhibition.  ( From Davidson medicine text book ) 3) Drug of choice for different seizure disorders  4) phe

GENERAL MEDICINE ASSESSMENT

Name  : Karnekanti Srinija Roll no : 63 Batch : 2019( 3rd semester) JUNE 2021 — BIMONTHLY BLENDED ASSESSMENT   Question No -1 *  First question is to go through the 10 answers of people  in following link and Write a summary on the case , tell about their work  LINK :- (https://generalmedicinedepartment.blogspot.com/2021/06/bimonthly-formative-and-summative_19.html?m=1 ANSWER :  *  I selected the case Regarding Pulmonalogy Here is the summary of the case  — This is a case of 55 year old female patient came to OPD with chief complaints of : shortness of breath ; pedal edema and facial puffiness — The patient is diagnosed with Acute exacerbation of COPD associated with right heart failure and bronchiectasis — she is a known case of Diabetes — The SOB is generally observed during the month of January (during which she works in the paddy field )and her first episode Of SOB observed 20 yrs ago — The systemic examination reveals barrel shaped chest , diffuse apex beat felt at 5 ICS , end ins